USICH Blog

By Jack Tsai, Assistant Professor of Psychiatry, Yale University School of Medicine

As the first day of open enrollment for health insurance and Medicaid through the Affordable Care Act’s marketplaces approaches, many states are still opting out or remain undecided about whether to participate in Medicaid expansion. One factor these states might consider in evaluating or re-evaluating their decision to participate is the impact of Medicaid expansion on homelessness in their state. Many adult individuals experiencing homelessness have complex medical and mental health problems and are uninsured or lack coverage for comprehensive services. But this may change with Medicaid expansion.

To examine these impacts on adults experiencing chronic homelessness, Samantha Artiga from the Kaiser Commission on Medicaid and the Uninsured, Dennis Culhane from the University of Pennsylvania, Robert Rosenheck from Yale University, and myself recently conducted a study using data from 11 U.S. cities. We found that nearly three-quarters of chronically homeless adults who will likely be eligible for the Medicaid expansion were not on Medicaid and many had serious physical and mental conditions that require a broad range of health care services they were likely not receiving. Compared to current Medicaid enrollees, those who did not have Medicaid coverage reported less use of health care services, including preventive services, and reported greater problems affording care.

Our study confirms that the expansion of Medicaid eligibility will have direct benefits on people experiencing homelessness. But the benefits don’t stop there. State budgets will also benefit from Medicaid expansion. People who are experiencing homelessness and relying on state-funded health care may be eligible for Medicaid, which will be nearly fully covered by the Federal government. Hospitals and health care providers will benefit by having fewer uncompensated visits. And Americans in general will benefit from less crowded emergency rooms and decreased government spending on health care.

Many people experiencing homelessness, particularly those who are chronically homeless, may not be fully aware of the benefits of Medicaid enrollment. Outreach and education about their eligibility and help completing Medicaid applications is essential. Moreover, people experiencing chronic homelessness are often reluctant to engage in primary and preventive care, and may be mistrustful of traditional service systems despite their needs. Health care and social services providers need to enhance their engagement strategies to overcome mistrust and make services more attractive. The National Health Care for the Homeless Council has developed factsheets, toolkits, and other enrollment materials. These may help providers encourage individuals who are experiencing homelessness to engage in preventive care and wellness, and apply for Medicaid and other forms of insurance coverage under the ACA.

We must also recognize that there is still a huge digital divide for people experiencing homelessness. As enrollment and educational materials are increasingly offered online and on computers, people experiencing homelessness may lack access to the internet and may not always have familiarity with computers. Therefore, the health care system needs to find ways to make this technology and education more accessible.

Our study shows the great potential that Medicaid expansion under the Affordable Care Act holds for people experiencing homelessness. States should recognize how participating in expansion can help them improve health care access, save public dollars, and end homelessness all at once. Meanwhile, in states that are already on board with Medicaid expansion, the focus should turn to building collaborative efforts to take full advantage of these benefits through concerted outreach, culturally competent engagement, and better access to technology.